Provider Demographics
NPI:1639419658
Name:MICULIAN, MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MICULIAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 HIGH SIERRA DRIVE
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:CA
Mailing Address - Zip Code:93221
Mailing Address - Country:US
Mailing Address - Phone:559-594-5853
Mailing Address - Fax:559-566-4295
Practice Address - Street 1:559 HIGH SIERRA DR
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:CA
Practice Address - Zip Code:93221-9509
Practice Address - Country:US
Practice Address - Phone:559-594-5853
Practice Address - Fax:559-566-4295
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14797103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical